PROJECT SUMMARY The burden of breast cancer is rising in low- and middle-income countries (LMICs), including in sub- Saharan Africa, and the gap between breast cancer mortality in low- versus high-income countries is widening. Data are highly limited about quality of and outcomes from breast cancer care in sub-Saharan Africa, though available evidence shows that quality is often inadequate. To reduce global disparities in breast cancer outcomes, better data are needed to guide effective breast cancer treatment programs that are cost-effective, feasible, and accessible to sub-Saharan Africa's general population. The goal of this K07 Career Development Award is to foster Dr. Lydia Pace's growth into an independent researcher with the skills needed to conduct rigorous investigation of breast cancer control in LMICs. Dr. Pace will benefit from mentorship by Dr. Nancy Keating, an internationally recognized cancer health services researcher and acclaimed mentor with expertise in cancer care quality, Dr. Lawrence Shulman, an accomplished breast oncologist and leader in global cancer control, and Dr. Jane Kim, an expert in cost- effectiveness with extensive experience in women's cancers in developing countries. Dr. Pace will pursue courses at the Harvard T.H. Chan School of Public Health and additional research training at Harvard University, affiliated hospitals, and the National Cancer Institute. She will take advantage of close collaboration with the organization Partners in Health and its experience in implementation science, economic evaluation, and cancer programs. She will work closely with her existing network of colleagues in Rwanda's Ministry of Health and Butaro Cancer Center of Excellence (BCCOE), Rwanda's first public cancer referral center. We will leverage this international partnership, existing research collaborations, and a robust data collection system to assess breast cancer care at BCCOE. The aims of this project are to 1) identify relevant breast cancer care quality measures for BCCOE and similarly resource-limited settings; 2) measure quality of breast cancer care at BCCOE and assess factors impacting quality; 3) assess time trends in breast cancer stage and survival at BCCOE, identifying the relationships between quality, health system and patient factors, and outcomes; 4) quantify costs of breast cancer treatment at BCCOE, and examine the cost-effectiveness of interventions to optimize quality. For Aim 1, we will utilize the modified Delphi method to engage an expert panel in refining a set of quality measures. For Aims 2 and 3 we will review BCCOE medical records and analyze the data using multivariate logistic and Cox proportional hazards regression. For Aim 4 we will perform detailed costing analysis and compare the costs and effectiveness of optimal versus current care. Together with strong mentorship, courses, and rich global collaboration, this project will facilitate Dr. Pace's growth into an independent investigator and prepare her for an R01 to develop interventions to improve breast cancer care at BCCOE, with the ultimate goal of reducing breast cancer mortality in Rwanda and beyond.